7/30/2018

Apparently in defense of the Democrat Party’s rising young star and everyone’s cute but clueless niece, Alexandria Ocasio-Cortez, who came under fire for her inability to square her socialist policies with finance realities, MSNBC host Chris Hayes let loose with this curious tweet:

I think a good answer for "How will you pay for your agenda?" is "We're a very rich country. We'll figure it out."

The idea that we are a “rich country” and thus can afford a lavish and extravagant level of socialism has been around at least since the days of Noam Chomsky and Howard Zinn. It’s a favorite trope of the obnoxious Michael Moore, who has also used the claim as justification for government-paid freebies. It’s also a variant of the old talking point “if we can put a man on the moon then why can’t we [insert progressive social policy priority here]” which is nearing a half-century of consistent usage.

But are we a rich country, or are we instead a country blessed by an amazing number of rich citizens? It’s a distinct difference. Warren Buffett as of today has a net worth of $83.3 billion, yet in 2015 he reported an adjusted gross income of $11.5 million and paid Uncle Sam just under $1.85 million. When running for governor in the 2003 recall race, righty-turned-lefty Arianna Huffington was embarrassed by the revelation that she had paid a mere $771 in federal tax the previous year, despite living in a home that was then worth $7 million. This sort of tax arrangement underscores the problems with relying upon the wealthy, whose incomes can greatly fluctuate on a year-to-year basis, to fill tax coffers. Sadly, it’s a conundrum well known to California Governor Jerry Brown, but cynically ignored by him in the interests of maintaining favor with the progressive zeitgeist which dominates the Golden State.

So is the answer then to tax wealth rather than income, a distinction that the Ocasio-Cortezes and Hayeses of the world seek to blur with their demagoguery? One kooky guy proposed such a thing nearly two decades ago, but he then faded into obscurity and was never heard from again. Even if the idea were to catch fire, it’s hard to see how it could pass Constitutional muster unless ratified by the states via an amendment.

If there ever was any reason to take the deep thoughts of Chris Hayes seriously, this tweet should be a powerfully preventative propholactic. Progressives are going to have to do the hard work of convincing us that our “out-of-control” health care costs can be addressed by activist government, providing that we massively raise our taxes to pay for their plans.

We are a rich country because a large percentage of the people (rich, poor and in-between) took care of themselves and contributed to the common good by not being parasites.

In contrast, lefties espouse a system where an ever-increasing amount of people depend on the state for food, shelter, education, transportation, healthcare etc.. The result of this system has been failure every time because the vital ingredient of incentive to improve is removed.

“No one loves socialism quite like a moron who has never experienced it firsthand. No one hates it like someone who has seen it up close. I walked around in its ruins overseas; it’s an abattoir. My wife escaped it, though her granddad didn’t – he rotted in Castro’s prisons for nearly two decades because he refused to play ball with the reds. Then he died. Oh well, gotta break a few eggs to create a paradise where somebody else pays for your college, right?

harkin, is England a socialist country? They have (GASP!) socialized medicine, and stuff. Canada too? Those two are not horrible countries.
Stop conflating socialism and communism. It’s like conflating conservatives and Nazis.

I should note too that Hayes followed up his tweet with the oh-so-predictable “we found trillions of dollars for the War on Terror and a Medicare drug program, so why can’t we find it for healthcare” canard, which completely ignores the fact that the Iraq War — no matter what you think of it — was a limited affair that was drawn to a close after five years. Somehow I don’t see us ending a Medicare for All program when it inevitably turns out to cost two, three, or four times what we thought it would cost. And I find it hard to imagine that Hayes opposed an expansion of an entitlement program (Medicare) during the Bush era, when the political party he supports had an even more extravagant and costly competing plan they were pushing.

Perhaps its because we’ve mostly avoided the socialist hell that everyone else seems to fall into? Jeff Bezos would have been stopped by the Competition Board in any socialist democracy. Same with Bill Gates or Warren Buffet. Elon Musk would have gone broke trying to get Paypal started, since the banking authorities would have viewed it as a threat (and just try to Paypal $1000 to an individual in Europe today).

We are a rich country, we have the lion’s share of all patents, we are the country that people come to for opportunity, because we respect individual effort, encourage it and reward it.

Socialism won’t cause us to become a poor country through spending. We’ll kill the golden goose long before we run out of the goose’s money.

Over the long term, cross-subsidies are far more inefficient than forthright taxing and spending. If the hospital is going to overcharge private insurance and paying customers to cross-subsidize the poor, the uninsured, Medicare, Medicaid and, increasingly, victims of limited exchange policies, then the hospital must be protected from competition. If competitors can come in and offer services to the paying customers, the scheme unravels.

No competition means no pressure to innovate for better service and lower costs. Soon everybody pays more than they would in a competitive free market. The damage takes time, though. Cross-subsidies are a tempting way to hide tax and spend in the short run, but they are harmful over years and decades…

…Lack of competition, especially from new entrants, is the screaming problem in health-care delivery today. In no competitive business will they not tell you the cost before providing service. In a competitive business you are bombarded with ads from new companies offering a better deal.

The situation is becoming ridiculous. Emergency rooms are staffed with out-of-network anesthesiologists. Air ambulances take everyone without question, and Medicare, Medicaid and exchange policies underpay. You wake up with immense bills, which you negotiate afterward based on ability to pay. The cash market is dead. Even if you have plenty of money, you will be massively overcharged unless you have health insurance to negotiate a lower rate.

Taxing and spending is not good for the economy. But it’s better than cross-subsidization. Taxing and spending can allow an unfettered competitive free market. …

That’s a salient point, Kevin M. By the logic of Hayes, Moore, and their ilk, Bermuda and Switzerland are rich countries. Bermuda has low income taxes and high consumption taxes which is quite regressive, and they are one of the very few nations in the British Empire that does not have national health care. Switzerland has very low taxes, and though health insurance is mandatory the requirement is on the individual to purchase insurance from the private market. Gee, maybe not offering a plethora of social services turns out to be what makes a country rich.

I’m actually torn on the issue of healthcare. Maybe we should do whatever is necessary to bring healthcare costs down to a some sort of manageability before we try to ensure that everyone has healthcare.

To cure the cost problem, some hospitals and doctors would probably have to go bankrupt. Theer is alot of debt being serviced.

But anyway the big problem is the way payments are structured. A much too high percentage is third party payments.

But you can’t even arrange to give everybody the same amount of money to spend on medical costs (insurance with no discriminaiton on the basis of re-existing conditions pretends to do that) because they have different needs. And the biggest medical problem is bad diagnosis which means some people need to see many different doctors.

The country is in debt, thanks to Obama…it more than doubled the national debt.
The country cannot pay its unfunded liabilities…such as medicare, medicaid, and social security…
Or the outrageous retirements of our public sector employees.
It’s to to reign in the spending…not stay at neutral

This is a very leftist site, so the P word rather than the S word is used to describe Venezuela’s collapse. But, if we are worried about the US remaining a rich country, it might be a good idea to review. I see both Trump stunts and Resistance stunts, and failed elite stunts as contributing.

“Anyone who thinks we can have Medicaid for All and not end up sentencing Charlie Gard to death is kidding themselves.”

More important is the removal of all monetary incentive to develop new drugs and treatments.
It’s the US Healthcare’s absurd money system that pays for all of that – without it everything would dry up to a trickle. The state of medicine would be locked in whatever year we’re in when it’s signed – no one would spend 2 billion dollars to take a drug to market and get paid pennies by the government.

“Perhaps its because we’ve mostly avoided the socialist hell that everyone else seems to fall into? Jeff Bezos would have been stopped by the Competition Board in any socialist democracy. Same with Bill Gates or Warren Buffet. Elon Musk would have gone broke trying to get Paypal started, since the banking authorities would have viewed it as a threat (and just try to Paypal $1000 to an individual in Europe today).”

Most of those are poor examples since they got rich AFTER the general wealth-spreading of the post-WW2 order and their success has in fact been at the general expense of localities.

“Gee, maybe not offering a plethora of social services turns out to be what makes a country rich.”

Alternatively, NOT ALLOWING MONOPOLIES ON SERVICES by governments OR businesses is what makes a country rich. The existence of the NHS has a chilling effect on all hospitals not willing to play ball in Britain, the existence of Telmexs’ monopoly crushes anything either locals or multinationals could do in Mexico.

If Bill Gates is rich but his product is The Only Game In Town and we’re all poorer for options as a result, is it really that hard to justify seizing his property under the Latin American model when America (and its people) increasingly resemble it?

Depends on what and how you calibrate a value to richness. Once upon a time you had a ‘gold mine’ in your pantry:

‘Some of the earliest evidence of salt processing dates to around 8,000 years ago, when people living in the area of present-day Romania boiled spring water to extract salts; a salt-works in China dates to approximately the same period. Salt was also prized by the ancient Hebrews, the Greeks, the Romans, the Byzantines, the Hittites, Egyptians, and the Indians. Salt became an important article of trade and was transported by boat across the Mediterranean Sea, along specially built salt roads, and across the Sahara on camel caravans. The scarcity and universal need for salt have led nations to go to war over it and use it to raise tax revenues. Salt is used in religious ceremonies and has other cultural and traditional significance.’ – source, wikisalt

There can be medical underwriting but all policiies should ahve the same premium. They should differ in the size of the deductible. Which might, in certain cases, be $1 million a year. (anything ese is nt properly called insurance. Insurance is for the unknown.)

The deductible should actually be a doughnut hole. The first dollars should be covered, but some of it should expire afetr one year and the rest after two. Before expiration it can be exchanged for medical gift cards or used to pay another person’s expenses.

Compamnied will set the maximum size of the deductible that the insured needs to pay. It cannt go above a certain level (say $30,000) If the person cannot pay it may be covered several ways. Besides normal boorrowing, there can be several ways of payiong for. Borrowing against atax refund (low limit) and against Social Security (which will not be acturally sound but the fed govt will incur a loss because people die) Also outright help.

Above the amount of the deductible paid for by the insured the insurance company will be responsible, but can sell the policy. We need something to make the underwriting honest. Companies will bid on what the actual outlay will be. The outlay will be covered by the federal government. They have to pay whatever is above their bid. they can contact the operson insured but cannot require anything. The original insurance company will suffer some loss if they overestimated. I’ve not got this worked out perfectly.

Every person may have a reguklar doctor who will be paid on a daily basis. And can switch es ofeten as they want.

No co-pays for unscheduled appointments. Co-pays only for scheduled appointments. A limit to the percentage of appointments a doctor can describe as unscheduled.

There needs to be many provisions to prevent surprise billing.

Any care not covered by insurance is charged at the 15th percentile.

Some costs, covered outright by fed govt. Maybe medical tuition, 85th percentile of cost of setting up an office.

Extra costs coverd by some form of consumption tax.

Whatever is done lots of checks of checksw and balances need to be created.

How long ago did you live in Canada, and what if any surgical procedures, specialists did you need to see?

Where I live we have a fair amount of medical tourism because the weather is beautiful, we have nice hotels, restaurants etc for family and recovery. Doctors and their families want to live here. We get a lot of Canadians and UK people, lots of folks from Argentina looking for quick access to top specialists; and of course we serve thousand of undocumented immigrants who use the emergency room as a free clinic for everything from first aid to gun shot wounds because its California

Maybe we should do whatever is necessary to bring healthcare costs down to a some sort of manageability before we try to ensure that everyone has healthcare.

This is where I think the Sanders/Ocasio-Cortez wing of the party is being dishonest. They believe that somehow we will bring healthcare costs down through “preventative medicine” and through negotiating prices with drug companies. But there is plenty of research suggesting that preventative care is overrated as a cost-control mechanism, and that negotiating prices drug won’t deliver significant savings but could hamstring the ability of the pharma industry to conduct research and trials.

This leaves us with two ways to reduce health care costs: reduce reimbursements to doctors and hospitals, or limit and deny treatment in many cases. As I have said before, though I disagree with single payer healthcare I don’t begrudge progressives for advocating for it, provided that they are honest about the effect it is going to have on the vast majority of us (longer waits and fewer treatment options). But you just know that the Sanders/Ocasio-Cortez wing is going to continue to parrot the Obama line of bulls*** and tell us that we will cover everyone, see no reduction in quality of care, yet somehow achieve price stabilization.

the Sanders/Ocasio-Cortez wing of the party is being dishonest. They believe…

I think they don’t think at all. They’ve contracted out their thinking to anyone who’s willing to say this can be realistic. Not that this doesn’t happen with many many politicians.

that somehow we will bring healthcare costs down through “preventative medicine”

At least that’s what Obama said, but I’m not sure anyone believes that any more. I don’t think Bernard Sanders is relying on that at all.

It’s wrong. Most “preventative medicine” even if it actualy prevents anything, and a lot doesn’t, doesn’t save money – it costs money. And in the long run, even much if what it did saves money, it costs money, especially afte you factor in Social security, because if peope die close to retirement age, they will have paid in to Social Security but will not collect – and if they live longer they probably will have an expensive illness anyway at some point later.

and through negotiating prices with drug companies. But there is plenty of research suggesting that preventative care is overrated as a cost-control mechanism, and that negotiating prices drug won’t deliver significant savings but could hamstring the ability of the pharma industry to conduct research and trials.

The whole drug development process is broken anyway. The government grantsa monopolyc, and then it ants to negotiate? It might be an idea to buy patent rights – then regulate things in such away so as not to drive up costs, as has hapepned to many generic drugs reduced to limited manufacturing.

This leaves us with two ways to reduce health care costs: reduce reimbursements to doctors and hospitals,

It doesn’t work. The system can be gamed.

or limit and deny treatment in many cases.

This doesn’t even cut costs. It tends to freeze them.

And did I mention that when you have single payer, you also get doctor strikes? Mayhbe not so bad as a lot of medical treatment is unnecessary or harmful.

As I have said before, though I disagree with single payer healthcare I don’t begrudge progressives for advocating for it, provided that they are honest about the effect it is going to have on the vast majority of us (longer waits and fewer treatment options).

Sanders’ “Medicare for All” would actually abolish all current health insurance, some of which is very good for some people. But he doesn’t advertise that.

Sanders’s makes ameta arghment, Sanders’ argument is like this:

“If every major country on earth can guarantee health care to all, and achieve better health outcomes, while spending substantially less per capita than we do, it is absurd for anyone to suggest that the United States cannot do the same”

Part of the reason for the better outcome is that they don’t have a drug problem, but also many other things are different.

The Mercatus Center, isn’t actually saying the United States cannot do that. They are saying (maybe they’re making assumptions that raise the cost but I would guess that even Sanders’ plan would cost more per capita, than say, France or Japan, is paying) that it can’t be done Sanders’ way.

It is telling that even THEY figure that the cost of Medicare For All will be more than what is currently spent on medical care.

So where does that leave Sander’s argument that:

“If every major country on earth can guarantee health care to all, and achieve better health outcomes, while spending substantially less per capita than we do, it is absurd for anyone to suggest that the United States cannot do the same”

He doesn’t spend substantially less per capita than “every major country on earth!”

One thing si for sure: You don’t get efficient markets when the government is spending the money (at point of sale – food stamps don’t drive up food prices.)

“There are four ways in which you can spend money.

You can spend your own money on yourself. When you do that, why then you really watch out what you’re doing, and you try to get the most for your money.

Then you can spend your own money on somebody else. For example, I buy a birthday present for someone. Well, then I’m not so careful about the content of the present, but I’m very careful about the cost.

Then, I can spend somebody else’s money on myself. And if I spend somebody else’s money on myself, then I’m sure going to have a good lunch!

Finally, I can spend somebody else’s money on somebody else. And if I spend somebody else’s money on somebody else, I’m not concerned about how much it is, and I’m not concerned about what I get. And that’s government.

And that’s close to 40% of our national income.”

Milton Friedman, in a Fox News interview in May 2004

What Milton Friedman said applies equally well to isurance as it does to government payments, except that insurance companies may want to underspend, but they often can pass on increased costs, and, the way they are regulated, it often pays for them to do so. Most of all they don’t want to spend much time and effort haggling over individual cases and balancing cost versus benefit, unless maybe the cost fo coverage is running into the millions for a patient.

When insurance is the vast majority of the market, the market doesn’t work.

The United States placed price controls on medical practice during World War II. My grandfather was a practicing physician, and I have in my possession a document from the Colorado Medical Association’s 1944 meeting which outlined what those state-mandated prices would be for 1945. Curiously, it is stamped as “Secret” and not to be shown to non-members. What is interesting is that doctors in Denver and Boulder could only charge as much as doctors in Conifer or Eads or Cortez. Imagine trying to implement that today, and limiting doctors in Bel Air and Knob Hill to charging what doctors in Needles and Yreka can charge.

Trump won because capitalism was working only for the rich. Voters told corporate donor class to shove jeb bush and the other 15 dwarfs where the sun don’t shine. Don’t think americans are “entitled to healthcare” according to your ayn randist libertarian conservative ideology? Voter said lets try trump before we let cute little alexandra ocasio-cortez and old bernie sanders put the rich and movement libertarian conservatives into re-education camp. Why do you bitch and moan that trump is preventing you from being loaded on to cattle cars and sent to a re-education camp run by noam chomsky?

It seems like “Steppe Nomad” is a rung down on the economic understanding ladder from “rural peasant.”

As for there being no alternatives to Gates and Microsoft, not only are these several, but two of them have supplanted Microsoft in all markets save one. But the statist approach would have been to limit Microsoft while granting them a regulated monopoly, like AT&T of old (which utterly stifled all telephony advances for half a century).

Until they can figure out that a hospital charging $30 for a Tylenol tablet

Considering WHY it’s $30, I’m surprised it’s so low. Once again, the lawyers are to blame.

Let’s say that someone is given a Tylenol, and shortly thereafter they have a stroke. It ends up in court and someone asks “So, who gave them that Tylenol, when did they give it, who took it out of which bottle from what lot, who carried it to the nurse, who ordered it and what were they thinking when they did that?”

At no point does anyone want to say “I don’t know.”

So, everything is recorded, cross-checked, signed, counter-signed, photographed and documented according to the current version of the procedure manual, for which training begins Monday.

Why do you bitch and moan that trump is preventing you from being loaded on to cattle cars and sent to a re-education camp run by noam chomsky?

Because we know that the video-game-and-internet-porn addicted Tide pod eaters and condom snorters along with the bearded Marxist sociology professors have zero chance of forcing us onto those cattle cars.

That is utterly not true. It just was working better for people outside the US than inside. It was working gangbusters for India, Indonesia, Central America and of course China. It was working great for low-wage workers imported into the US. It just had forgotten the American worker and the fact that said worker casts a vote.

he problems with relying upon the wealthy, whose incomes can greatly fluctuate on a year-to-year basis, to fill tax coffers. Sadly, it’s a conundrum well known to California Governor Jerry Brown, but cynically ignored by him in the interests of maintaining favor with the progressive zeitgeist which dominates the Golden State.

The problem is that receipts are variable, and rise more in good economic times and drop in bad economic times. This is a problem when budgeting.

80 do the math every election voters become 1% less white. Maybe you think non whites love libertarian conservatives. Maybe you think 16 dwarfs would have gotten more non white votes then trump. If you do you must believe in the tooth fairy too! The democrats will incrementally extend their agenda. wait until president alexandra ocasio-cortez in 2024 says time to impeach conservative supreme court justices out. If they haven’t “died” in office already.

Of course you can. You just can’t be surprised when you go out of business because nobody is willing to pay that price. Or you can’t be butt-hurt when someone else opens up an X-ray shop and only charges $500 for a set of X-rays.

Several panelists talked about the wide variation in price for the same medical treatment in the same metropolitan area. In Atlanta, Gaynor said, it can cost 600% more to have a colonoscopy in one location than another. The problem is that patients usually don’t know about local price variations because they’re generally not given cost information by health care providers or insurers.

That’s not true in other countries. “There are prices on walls in doctors’ offices in France. In Australia, people are entitled to binding estimates before they go in for elective surgery,” said Dr. Elisabeth Rosenthal, editor in chief of Kaiser Health News.

I would add that I (still) think that people should have some skin in the game, so to speak and have to pay some of the bill. If you have medical insurance, you don’t necessarily care if one price is $600 more if you don’t have to pay a penny more for it. That kills competitive prices, right there.

And every election the remaining white voters become more conservative, as they resent being the object of scorn and derision by the oh-so-tolerant left. Take Breitbart with a grain of salt — Heaven knows that most of us here do — but they quote an alleged Reuters-Ipsos poll showing that white males 18-34 have moved ten percentage points since Trump’s election from favoring Democrats to favoring Republicans. The burning question is whether the radical multicultural grievance left can hold together its coalition long enough to elect Democratic Socialists. I kind of doubt it.

I would add that I (still) think that people should have some skin in the game, so to speak and have to pay some of the bill. If you have medical insurance, you don’t necessarily care if one price is $600 more if you don’t have to pay a penny more for it. That kills competitive prices, right there.

On that point, I think that the vast majority of commenters on this site are in agreement. I’ve said before that I think we need to divorce the idea of “health insurance” from “health care coverage.” I’m even willing to consider some sort of nationalized health insurance policy, so long as it is coupled with making individuals responsible for paying for their day-to-day medical charges such as doctors appointments, prescription drugs, lab tests, etc. Let people establish tax-free medical savings accounts, and have the government provide vouchers to the poor so that they can pay for care. Then allow doctors to set up fee for service arrangements. Sure there will be some people who will be forced to choose whether or not to go on expensive drugs or undergo expensive tests, but it will ultimately be up to the consumer, not an insurance or government bureaucrat to make those decisions.

I’m even willing to consider some sort of nationalized health insurance policy, so long as it is coupled with making individuals responsible for paying for their day-to-day medical charges such as doctors appointments, prescription drugs, lab tests, etc.

One problem with that is that some people won’t spend anything – yet they should be willing.

So I would give everyone an amount, like 41600, which is perishable. I wuld have some expire after oine eyar and some of it sfter two – but still allow t t be converted to gift cards. Whoe issuanc must be somewhat limited or else medical practices could sell too much of them, It is irrelevant what the original source of the money is: food stams do nt cause peole not to care about the price of food.

As for doctors appointments the whole pricing system has to be changed.

Primary care doctors should get paid by the day. So there would be more telephone conversations and fewer useless appointments or appointments just to get oprescritions filled and tests updated.

Scheduled appointments should cost the patient more nd pay the doctor less than unscheduled ones, rather than the reverse, but to prevent gaming the system there should be alimit on how many unscedukled appointments a medical practice can claim.

Let people establish tax-free medical savings accounts, and have the government provide vouchers to the poor so that they can pay for care.

Yes, or even McAcin’s 2008 plan of gving everyone ZX number of dollars. But I proposed the charge be the same, the deductible vary, and people who at at high risk have the extra risk covered. There should be adoughnut hole, and away for everyone to fill the doughnut hole.

And people need to be able to sped more when they are not getting good diagnosis.

Prices can vary now by a factor of 6, but the charges of even the cheapest provider can be way too high. A arge variance is probably a sign that everybody, including the cheapest provider, charges far too much.

Sowell gives the following example, and immediately connects it to socialized medicine:

Why don’t we all live in houses on the beach? Most people who want an ocean-front home can’t afford it because the price is too high.

Sowell asks: if the government passed a law capping the price of ocean-front housing at a level everyone can afford, could we then all live at the beach? The answer is obviously “of course not”. The high price of an ocean-front home reflects something real about the state of the world: the scarcity of, and high demand for, the resource. Passing a law won’t change that, it will just mean that rationing of ocean-front housing will happen by some means other than pricing, for instance political favoritism, luck, etc.

Capping prices only exacerbates the problem of scarcity, because it disincentivizes the provision of increased supply. Rent caps lead to no more housing units being built, or the caps being evaded by building luxury units that are not subject to the cap. Price controls also lead to lower quality products being provided, since there is no way to recover the costs of higher quality. Capping the price of health care will likewise result in reduced supply and quality of services and facilities.

In short, trying to control prices distorts the economy and prevents resources from going to where they would have the highest value.

Dave, I can see your point, but I was mainly interested in preventing egregious price gouging, but nothing more. E.g., see above, “..it can 600% more to have a colonoscopy in one location than another…”

There needs to be also better access to medical records so they can be transferred to other physcians.

Yeah, Bill Clinton and Newt Gingrich were touting this together twenty years ago, yet we have taken only very tentative steps of making this a reality. This is especially important for senior citizens who get over-proscribed medications because their various specialists don’t know what other drugs they are taking and the patient oftentimes doesn’t give a full accounting to each doctor.

Leftist concept of economics; Government like Suge Knight holds typical rich white people like Vanilla Ice over a 14th floor hotel balcony by their ankles, thereby having Vanilla Ice’s cash fall upon the great unwashed masses below. It’s insane. It was also US government monetary policy for 8 years.

103 this doesn’t apply in monopolized markets. Many parts of the country don’t have choice of hospitals. Medicare caps on dialysis would be a good example of price caps being more effective than open market.

“The American communist party which became an appendage of the Kremlin under grandpa browser, split off from the socialists”

And large corporations divide and rebrand whenever one brand gets too toxic or too niche. The basic business strategy remains the same.

To quote someone even better references someone better than them both:

“There is no European Christendom. There is only one genderfluid system of systems, one vast and immane, interwoven, interacting, multivariate, multinational dominion of fiats. Petro-dollars, electro-dollars, multi-dollars, bitcoin, litecoin, dogecoin, and shekels. It is the international system of cashless transaction which determines the totality of life on this planet. That is the natural order of things today. That is the atomic and subatomic and galactic structure of things today! And YOU — pro-America dissident — have meddled with the primal forces of nature, and YOU… WILL… ATONE! Am I getting through to you, Mr. Trump? You get up on your little hundred-and-twenty-one inch screen and howl about America First. There is no America. There is no democracy. There is only Facebook, and Twitter, and Amazonia, and Netflix, HBO, Goolag, and Gamergate. Those are the nations of the world today. What do you think the Russians talk about in their councils of state, Karl Marx? They get out their linear programming charts, statistical decision theories, minimax solutions, and compute the price-cost probabilities of their two bit phishing scams and Facebook ad investments, just like we do. We no longer live in a world of nations and ideologies, Mr. Trump. The world is a college of corporations, inexorably determined by the immutable bylaws of sodomy. The world is a business, Mr. Trump. It has been since man crawled out of the slime. And our genitally malformed anti-social autistic children will live, Mr. Trump, to see that… perfect world… in which there’s no war or famine, oppression or brutality. One vast and ecumenical holding company, for whom all men will work to serve a common profit, in which all men will hold a share. All hormone replacements provided, all anxieties tranquilized, all boredom amused. And I have chosen you, Mr. Trump, to KNEEL BEFORE THE CHAMBER OF COMMERCE.”

How do we square the circle and properly dismiss the idea of taxing “wealth” (the sum total of all assets described in various piles of paper) while embracing the idea of taxing “property” (the guess about what a parcel of land might sell for, if sold in an open market, along with the existing structures and in some jurisdictions, the contents / commercial inventory) ?

That is, it seems to me we DO tax “wealth”, already, without deep thought or much protest. And various special interests play various games to avoid the tax and beg legislative favors, just as we do when we tax earned income, or investment income, or unrealized capital gains, etc etc.

A couple of comments about healthcare, in no particular order: (1) two parts of Obamacare should be kept, the banning of preexisting conditions and keeping kids on parents’ plans until they turn 26; (2) Mr. Cochrane has a point about cross-subsidies; (3) Trump’s replacement plan for Obamacare outright sucked; (4) for-profit healthcare insurance provides a perverse incentive because insurers are more profitable the more they deny health coverage to their customers, which is immoral; (5) our spending on healthcare is massively inefficient compared to other developed nations; (6) there are healthcare insurance systems in other developed countries that are superior to ours. We don’t have to go single-payer when we can follow the Swiss or Holland models, for example. But then, I had a long conversation with some Aussies, and their plan works pretty darn well, but it would take such a monumental restructuring here that it probably wouldn’t be worth it.

Paul, not one person on this planet, Trump included, has an inkling of that “Trumps replacement plan for Obamacare” was. RYAN’s plan was the best of the bunch, killed by “conservatives” who were carrying water for the Democrats. It’s main fault was that it was workable.

The thing that stops all health care reform in the US is that 90% of the insured do not pay the actual cost of their plans, and are not taxed on the subsidy.

Obamacare tried to tie the other 10% (mainly self-employed) to the never-insured, a largely poor and sick contingent, and then subsidize the care of these poor and sick folks so that they really USED their insurance.

And of course, the self-employed who were forced into the same pool got hammered with the very high average cost of pool members.

And the 90% who were largely untouched by the fiasco were the ones with all the [ignorant] opinions.

1) you can’t have guarantee issue without pre-existing limitations. So until there is an iron clad mandate to have coverage the math won’t work.

4) more stupid talk, about 80% of insurance payments come from non profit plans. The most expensive, in efficient, and fraud prone plans are non profit. Premiums are based on claims plus a percentage added for administration and profit, so in fact, the more carriers pay the more they make as long as the person can pay the premium and doesn’t wait till they have claims to buy the policy.

Paul, not one person on this planet, Trump included, has an inkling of that “Trumps replacement plan for Obamacare” was.

Nonsense. He told everyone very explicitly:

Scott Pelley: What’s your plan for Obamacare?

Donald Trump: Obamacare’s going to be repealed and replaced. Obamacare is a disaster if you look at what’s going on with premiums where they’re up 45, 50, 55 percent.

Scott Pelley: How do you fix it?

Donald Trump: There’s many different ways, by the way. Everybody’s got to be covered. This is an un-Republican thing for me to say because a lot of times they say, “No, no, the lower 25 percent that can’t afford private.” But–

Scott Pelley: Universal health care?

Donald Trump: I am going to take care of everybody. I don’t care if it costs me votes or not. Everybody’s going to be taken care of much better than they’re taken care of now.

Scott Pelley: The uninsured person is going to be taken care of how?

Donald Trump: They’re going to be taken care of. I would make a deal with existing hospitals to take care of people. And, you know what, if this is probably–

Scott Pelley: Make a deal? Who pays for it?

Donald Trump: –the government’s gonna pay for it. But we’re going to save so much money on the other side. But for the most it’s going to be a private plan and people are going to be able to go out and negotiate great plans with lots of different competition with lots of competitors with great companies and they can have their doctors, they can have plans, they can have everything.

Main take-aways of the Trump plan:

1) Everybody will be covered, and everybody’s coverage will be better than under Obamacare.
2) The government will pay for the uninsured.
3) Trump “will make a deal with existing hospitals to take care of people.”
4) Everybody can have everything.

I guess the negotiations with “existing hospitals” are still going on in secret.

I am always fascinated by blog healthcare threads. Lots of people spout off the most ignorant stuff. And then you find out who works in the medical/insurance/industrial complex in some way or other, because the air of “knowing what you are talking about” shines through. I think Nate Ogden has outed himself, probably as someone on the insurance or HR part of the business. (See #144)

Healthcare is a harder issue for us than most countries because we subsidize a lot of global medical innovation and healthcare innovation by not having single payer healthcare. If we go medicare for all, innovation will shift to government priorities, cultural fads turned into governmental priorities, and the procedures not covered by Medicare for All. Of course, government abortion on demand will put an end to Planned Parenthood’s cash cow, so there is that.

now, the notion of no preexisting conditions, there’s a reason that wasn’t included in the hmo bill, because the cost is prohibitive, same as with the age 26 rider, now as to the benefit package, not everyone needs birth control, included, or gender reassignments or whatever, that’s what’s spikes the price up,

But there are plenty of specific laws on the books that could apply if Trump’s presidential campaign is found to have collaborated with Moscow, including a conspiracy to defraud the United States. There are also laws against election fraud, computer hacking, wire fraud and falsifying records, if those apply.

“In Kentucky, a major pension plan covering state employees had about 16% of what it needs to fulfill earlier promises, according to the Public Plans Database, which tracks state and local pension funds, based on 2017 fiscal year figures. A fund covering Chicago municipal employees had less than 30% of what it needed in that fiscal year, according to the same database. New Jersey’s pension system for state workers is so underfunded it could run out of money in 12 years, according to a Pew Charitable Trusts study.

When the math no longer works the result is Central Falls, R.I., a city of 19,359. Today, retired police and firefighters are wrestling with the consequences of agreeing to cut their monthly pension checks by as much as 55% when the town was working to escape insolvency. The fiscal situation of the city, which filed for bankruptcy in 2011, has improved, but the retirees aren’t getting their full pensions back.

“It’s not only a financial thing,” said 73-year-old former Central Falls firefighter Paul Grenon, who retired from the department after a falling wall punctured his lung, broke his back and five ribs, and left him unable to climb ladders. “It really gets you sick mentally and physically to go through something like this. It’s a betrayal, as far as I’m concerned.”

As you know, healthcare is devilishly complicated, the root cause being that the people using are usually not the people paying the bulk of the cost. The second cause being that we sort of acknowledge that good health is sometimes an accident and sometimes the result of lifestyle choices, and we don’t know how to allocate the consequences of that through society.

Most politicians don’t have a clue because most people don’t have a clue, and most people want their expensive procedures paid for, and don’t want to pay for anyone else’s. I suspect there are more rational ways to do healthcare than the often insane system we have created. But our system evolved the way it did for a reason, and it serves most of society well enough that there is not a huge demand to switch to something else.

That interests me. Is there a difference between the standards for denials of claims and the standards for pre-authorization or pre-certification of procedures/medications? My experience over the past 30 years is that some pre-authorizations are denied solely because of cost concerns.

That gets tricky, cost and cost effecisy are two very different things. Providers get paid for service not results. It’s very easy and common for providers to try anything and everything regardless of how likely it is to work.

More than any other country we are willing to spend billions on long shots and a couple extra weeks of life. Based on the premium people are paying, there has to be limits on what’s covered. This is standard in all other systems and denied at a much lower bar than what’s acceptable in America.

Once the system or courts determine something is appropriate care it’s covered and calculated into premiums. People wanting care they didn’t pay for in their premiums has always been a battle.

it’s not so much that we’re willing to spend billions on long shots it’s just when you have old sick people that could die soon you have to start doing surgeries and stuff on them so you can run up your billings

Once the system or courts determine something is appropriate care it’s covered and calculated into premiums.

That has not been my experience with IVIG and other gamma globulin products. Coverage varies depending on the insurance companies’ financial health, not the appropriate treatment for a disease or the patient’s health. The insurance companies have to watch their bottom lines and they often do it by restricting high-dollar treatments like IVIG that impact small segments of the population (like immune-compromised patients).

Pointing out a breaking news story in a thread that’s been open for over 22 hours is not “thread jacking”.

Pointing out a story that has nothing to do with the topic of the original post most certainly is threadjacking. This isn’t the only thread where you’ve brought up side topics. It’s annoying when anyone does it. If you want to write about something no one else is talking about, start your own blog. Or maybe ask Patterico for a guest post spot.

The usual standard is whether the expense is reasonable and customary, and not an experimental treatment. Of course, insurers, or in my world and Nate’s world, the employer that is self-insuring the benefit tries to keep their costs predictable. But an evaluation of a medical procedure is not based on “gee, my claims experience stinks this week and I am going to have to sock away more reserve money I don’t have unless I deny this.” It’s “does anyone else do this, and pay so much for it, or is there a cheaper way to accomplish the same outcomes.”

Um, no. Insurance companies set premiums based on past performance, and it’s a price-competitive market, not counting self-funded corporate plans. If they have to pay out more in one year, they have to adjust their premium levels for the following year, and since their administrative costs are not all that different from non-profits and because they have to factor in profit, they’re squeezed on premiums and payouts. This is basic economics that you’re missing.

How many of those people are in a market that has a choice of carriers?

Non Profit is an ownership and tax status, not an operating policy. Many non profits have higher margins than for profit. It’s a fallacy that non profits are inheridently cheaper due to their status. Non Profit hospital chains like Cleveland Clinic being a great example.

I don’t have the numbers in front of me but are you aware how many insurance companies are actually owned by non profit provider systems. How do you square that in your denial of claims to make more money argument?

187 — That is what politics and partisanship can do. I think, early on, the idea of letting women access to easy birth control without some sort of professional seal of approval was horrifying to Republicans. Time passes. Now the idea of birth control being easy to get spooks Democrats because they lose the boogy man of Republicans trying to saddle you with extra babies!!

“Over the 5 year time horizon, the model estimated the incremental costs and QALYs of IVIG treatment compared to corticosteroid treatment to be $124,065 and 0.177 respectively. The incremental cost per QALY gained of IVIG was estimated to be $687,287. The cost per QALY of IVIG was sensitive to the assumptions regarding frequency and dosing of maintenance IVIG.

Conclusions
Based on common willingness to pay thresholds, IVIG would not be perceived as a cost effective treatment for CIDP.”

But an evaluation of a medical procedure is not based on “gee, my claims experience stinks this week and I am going to have to sock away more reserve money I don’t have unless I deny this.”

Not always.

DRJ, who where the insurance companies and was it group or individual?

IVIG has always been a problem due to bloated markup and misuse.

I’m curious if you ever asked the hospital why they were it up over 1000%?

Nate Ogden (21def0) — 7/31/2018 @ 10:37 am

Blue Cross Blue Shield and Aetna. Aetna was much better to deal with of the two. We have used hospitals for infusions but typically we used home nursing, and in the past 10 years sub-q self infusions. But getting the product is always a challenge when the insurance companies are financially challenged, and we have used this for two people for 30 years.

As you can see, the physician office earns a gross profit per claim of $748, equal to a 16% margin. The hospital, however, earns a gross profit of $6,923 and a margin of 68%. If the hospital is able to acquire the product at the discounted 340B price, the margin becomes $8,055 (79%). That’s more than four times as much as the drug manufacturer received for the same product!

As long as such financial windfalls prevail, hospitals will be slow to adopt biosimilar drugs. See the discussion in Section 6.3.4. of our 2016-17 wholesaler report.

By the way, the prices have varied from $5000/10 grams to over $100,000, although generally it is around $9,000 with an average mark-up. The product was not available in the home consumer market during Desert Storm and has been more expensive during other military campaigns because the military took more and restricted supplies. But the biggest problem we’ve ever had was after ObamaCare when the insurance companies really clamped down on the immune-compromised. There is a special law that protects immune-compromised Medicare patients from this, but nothing for the rest of us.

Aetna actually considered our medical issues, albeit only on appeal, and all our policies have been PPOs (either group or individual). But you don’t know enough about IVIG if you have to ask for this much detail, so don’t bother to answer because I know you are not informed about IVIG and the immune-compromised. Sorry I wasted our time.

As you can see, the physician office earns a gross profit per claim of $748, equal to a 16% margin. The hospital, however, earns a gross profit of $6,923 and a margin of 68%. If the hospital is able to acquire the product at the discounted 340B price, the margin becomes $8,055 (79%). That’s more than four times as much as the drug manufacturer received for the same product!

As long as such financial windfalls prevail, hospitals will be slow to adopt biosimilar drugs. See the discussion in Section 6.3.4. of our 2016-17 wholesaler report.

This seems like a really strong example of why HMOs are the smart way to control costs.

When the hospital is spending some external insurance company’s money, they have no reason to economize. But when the people spending the premiums are the same as the people receiving the premiums, you can be pretty confident the premiums will go farther and waste will be reduced.

(I’ve had Kaiser-Permanente through work for close to 20 years, and nothing but positive experiences)

The provider owned HMO has every incentive to maximize premiums. There were and are countless provider owned HMOs and Carriers and I’m not aware of even one that has meaningfully outperformed the market.

197 You sound like Beldar, it’s always the ignorant that question the knowledge of the other side to hide what they don’t know.

You never did answer the question and it makes a huge difference. You said the carriers denied when they where in financial trouble but can’t explain how you know they where in this condition. BCBS is not a carrier, it’s an association of carriers. There are 36 BCBS members, which one you where with makes a huge difference. Some small ones like Idaho or Montana are small compared to Aetna on health. Anthem or Empire are huge, compared to Aetna they haven’t been in financial distress.

Your claim that payment or denial is based on financial health doesn’t pass the smell test.

Individual policies are heavily regulated at the state level, much less likely to have certain types of services denied as States are more uniform on whats covered in their state.

Group policies are far less regulated, if it is an ERISA plan it’s exempt from State regulation all together. The variance in what is covered and how can vary from group to group. That has nothing to do with the carrier or their financial health.

The questions I asked have nothing to do with the administration or prescription of IVIG, it has to do with your BS claim. If you can’t support your claim bashing insurance companies just don’t respond. To attack me saying I don’t know what I’m talking about isn’t going to end well.

It doesn’t matter how many people use it. To pay $4 in claims requires the carrier to collect $5-$5.50 in premium. For every dollar they pay out they need to bring in 25-30% more in premium for individual and small group plans. Larger self funded 10-20% more.

It has never made sense to pay small known expenses through insurance. It just adds cost.

My knowledge is based on years of experience with IVIG and related products, including insurance appeals and appeals to my State’s insurance board and the information revealed by or obtained from the insurance companies during the past 30 years. In addition, it is buttressed by the experiences of many other immune-compromised patients and legislation addressing aspects of this problem with Medicare patients as shown at one of my links.

PS – Did I miss your answer to my question — do you deal with claims or pre-authorizations? If you deal only with claims then you never see this, because claims for this medicine are only paid if they are preauthorized. Everything you have said suggests to me that you only see the claims side.

Non Profit to me always looks like use any surplus cash for travel, meals, hotels, flights, cruises, bonuses, per diem, car service board of director payments for meetings etc until there is no more $$ left over.

LA DWP had a non-profit with a $24M slush fund in it to study safety. It was paying board members and sending them along with chosen politicians on junkets around the globle’s hotspots to study safety here there and everywhere, usually in places with nice beaches and casinos

204 “PS – Did I miss your answer to my question — do you deal with claims or pre-authorizations?”

We dealt with both. We designed and administered the plans so everything went through us. Especially on Rx I did a lot of that in house because it was such a cost issue. I would hire pharm techs and have members call in on all brand name Rx to try and find savings.

When it came to IVIG that was always a lot more work because it would be a reinsurance claim that needed reported to that carrier for reimbursement.

Majority of the time we also dealt directly with the provider trying to negotiate price and the treatment plan.

Just because something is per-authorized doesn’t mean it will be paid and just because something isn’t per-authorized doesn’t mean it won’t be paid.

“Cleveland Clinic ended 2016 with operating income of $139.3 million, down 71 percent from operating income of $480.2 million in 2015. After factoring in nonoperating gains, the system recorded a net income of $513.5 million in 2016, compared to $618.2 million in the year prior.”

That’s after a generous CEO salary, highly compensated staff, and many beautiful new buildings.

There are times when IVIG is administered as an emergency medication, such as an instance we had with severe GBS/paralysis, but in my experience even then the hospital and insurance carriers want preauthorization. I don’t know of any carrier that will reimburse IVIG therapy over several months without preauthorization. Is that something you’ve seen, Nate?

If so, isn’t that unusual since every insurance policy I’ve ever seen/researched lists IVIG as a medical benefit (not a pharmacy benefit) that requires preauthorization for all but emergent uses. And my guess is that emergent uses almost always occur in the hospital, and even in emergencies the hospitals I’ve dealt with have required preauthorization before administering IVIG.

When it came to IVIG that was always a lot more work because it would be a reinsurance claim that needed reported to that carrier for reimbursement.

Are you saying that you know of insurance carriers that have reinsurance agreements for IVIG claims? In other words, are you saying that carriers transfer portions of their risk to other parties by agreement to reduce the likelihood of incurring large obligations?

If so, I never realized that so you have renewed my interest in this conversation. How common is that? I won’t ask you who does it, although I did reply when you asked the name of my carriers so I hope you will reciprocate with the names of carriers that you know reinsure IVIG claims.

Or are you saying that your group handled claims for self-insured groups but there were reinsurance agreements for large claims like IVIG? If so, did your group handle the preauthorizations for those claims or were they done by the carriers actually underwriting the claims?

I bet you are talking about stop-loss policies for self-funded plans. If so, who handles preauthorizations? If you did, did the reinsurers give you the criteria you used in deciding when to authorize the more expensive procedures or medications like IVIG? How did that work?

215 some we handled in house, others we would hire a firm that reported back to us.

We wrote the plan docs that outlined pre auth requirements. Reinsurance carriers weren’t involved in day to day operation of the plans, they would review case notes after the fact when claims were submitted to them.

In some cases we would bring in outside doctors to review and consult on cases.

Depending on the care requested standards are determined by what is approved, what is done in the market at large, potential for successful outcome, other potential treatments, what other treatments were tried.

How providers cost compared to other sources and medicare. Medicare guidelines were taken into consideration when applicable.

Reinsurance didn’t cover IVIG specifically but would cover groups when claims on one individual exceeded a set amount (specific insurance ) or claims on the entire group exceed a set amount (aggregate insurance )

Fully insured carriers also almost always buy reinsurance. For risk and accounting reasons it’s needed, it spreads risk and for reserves it simplifies accounting. When lifetime and annual limits where removed it was hard on the books to reserve for an unlimited event, Reinsurance caps the exposure allowing for simplified reserve calculations.

The large Reinsurance companies usually aren’t ones with known names and large retail operations. Lots of old European carriers and some Asian ones.

There is a small market for a couple specific risk like transplants, groups can buy a policy that will off load the lifetime cost directly associated with the transplant while the health plan retains all other risk.

I’ve seen similar policies for cancer and I think maybe dialysis. Never seen one specific to IVIG or drugs.

212 government plans historically have been extremely lax and generous. Some union plans historically were very generous.

In an emergency IVIG would be administered then the pre auth would be required to be done within 48 to 72 hours.

It’s been a few years but I saw many poorly written plans that we took over or quoted that didn’t have any provisions outlined or pre auth requirements.

My sales approach was cost management so we required everything be pre certified so we got a heads up before cost were incurred. When we took over plans we would rewrite their plan docs with stricter language.

I recall one client that was a city that got hit with a bad IVIG claim, finally got rid of the claim then a different person hit. City didn’t have the appetite to fight with provider again so they just rolled over and paid it all. Very questionable use on the second claim, young teenage girl that had lots of other potential options.

Did you notice at one of my links that Aetna in California did not have doctor review of pre-appeal IVIG authorizations? That’s not how it should work, and I think it’s conceivable carriers like that could give guidelines to their non-MD reviewers that let some patients fall through the cracks. My impression is that what Aetna admitted may not be unusual.

I can’t think of any reason other than cost-cutting that an insurance company would not hire/use doctors to conduct medical reviews of IVIG preauthorizations (or at least of denials of preauthorizations), but we know it occurred. My experience is that it probably isn’t limited to one company. It also supports my belief that companies sometimes let cost concerns affect how they handle preauthorizations. That may not be true of your company — and, if so, good for you — but it seems to be happening, don’t you think?

Of course, cost concerns are a part of the way insurance companies design their packages, and the way they address claims. No business survives if they are indifferent to costs. To avoid the large impact of a class of diseases, an employer or an insurer may choose to exclude coverage for a specific type of procedure, or impose a specific preauthorization, or other specific requirements related to a condition or a treatment. Those requirements can change from policy year to policy year. It isn’t clear to me (and it’s probably not clear to you) whether you are having problems with a self-insured plan (meaning the insurer is playing with the your employer’s money, not its own), or a fully-insured plan.

The specific requirements in such a situation are supposed to be disclosed, and the exclusions of such a policy are supposed to be listed. Due to the complexity of health plans, it is hard to find those exclusions in the documents you are given.

What generally can’t happen legally is the sort of arbitrary and capricious behavior you have been describing in your posts. If the insurer/employer has written down in their Summary Plan Description that a procedure is not covered, they don’t have to cover it. If they have written down that an expense will be covered only if it is reasonable and customary (and what that means is defined somewhere), they don’t have to cover expenses over the reasonable and customary amount. If they have determined that your treatment is experimental (and they have written down what that means in the Summary Plan Description), they don’t have to cover it.

BUT, the determination by whoever is denying your claims has to be consistent from one participant to another. You don’t make claims decisions on whether the reserve is high or low today. You may make program redesigns if your premiums aren’t covering the claims you are paying, and those tend to take effect at the beginning of the next contract year.

We know what kind of plan we have. We read and understand the plan and coverage every year and, in fact, before we buy coverage. Having immune-compromised children that depend on this medication to survive for their entire lives means we know the details. I even provided links showing this is a problem. It happens but I grant that it is rare because the diseases are relatively rare.

Tell me, Appalled, do you think it is acting in good faith under an insurance contract to use nurses or laymen to deny a procedure/medication that a doctor has prescribed for a patient, to refuse to let doctors review the denial, and to not tell the patient an MD was not involved in the review?

You realize that people with these diseases don’t go to average PCPs, right? People with these diseases are sent to highly trained specialists in the best medical centers. Our children were diagnosed at Mayo and the NIH.

Having an insurance company nurse tell us they don’t need these medicines (that they have used for 20-30 years) is absurd, but it happens repeatedly because IMO they (1) don’t care and (2) want to save money.

An insurance company is not going to use high priced low productivity doctors to make determinations on initial claims. They are going to use special scrutiny on a claimant with significant high priced claims in the past, and they may be more prone to deny than you feel they should be. You are correct that they are reluctant to pay in cases such as yours, and preauthorization is a lever to contain costs.

Your family is losing the insurer money. I assure you that a single-payer system would treat you much the same way, except there would be a lot less levers the push, because there are fewer incentives for a government to police itself.

Thank you for your response, Appalled. After reading it, it’s clear that I have not made my position clear anf I welcome the opportunity to clarify it here.

First, thank you for acknowledging my initial point that insurance carriers use preauthorizations to control costs.

Second, I think one way we differ is that you think that is allowed and I don’t. I certainly agree that insurance carriers can and should decide to use less expensive staff where possible. But I don’t think that cost-cutting decision is in good faith if it becomes an excuse to deny valid, policy-covered requests for preauthorization of prescribed medicines — simply because the staff is not knowledgeable enough to understand. Instead, IMO any and all DENIALS should be reviewed by MDs or the carrier is not acting in good faith.

Third, I never raised single-payer because I know the immune-compromised population will be the first casualties in government healthcare. They already are, which is why Medicaid almost always denies coverage and a special law had to be passed to prevent Medicare from denying coverage.

For now, the government is betting that it can afford to pay for the immune-compromised population that can live to be 65 and qualify for Medicare. It’s a good bet. It won’t do that for Medicaid, now or IMO ever.

Instead, carriers may choose to wait for MD review until patients file appeals of any denials. That adds time, money, and often causes an interruption in care. Some patients give up or are too sick to file appeals, so it works but that is not acting in good faith if it is part of the carrier’s plan to cut costs.

The general rule, if your plan is sponsored by a private employer is that:

in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment;

See 29 CFR 2560.503-1(h)(3)(iii) Aetna violated that rule (badly) in the CNN article you cited upthread. An average insurer/TPA who uses a nurse doesn’t necessarily run afoul of that rule, but runs the risk. This rule is probably what is saving your bacon when you appeal.

That is the similarly-qualified professional rule. I am familiar with it and it has helped us twice, but that is different than what I am saying. IMO a prescription by an MD cannot be “not medically necessary” by a nurse or layman. They can make a recommendation and an MD may agree with them, but a denial should be done by an MD.

FWIW in my experience most MDs in that situation have referred our preauthorization to a specialist for review, because even they don’t have the training to make the call. They know it is not good fsith to use ignorance as a basis for a denial.

I don’t want to put words in your mouth DRJ; but I get the impression you feel if a doctor says Medical treatment is necessary and appropriate then it should be paid for by insurance.

I can’t begin to tell you how much wasteful, unnecessary, inefficient, and downright wrong treatment doctors order. Some studies have placed it as high as 30%.

Everything people hate about insurance is a counter to abuse of plans by members or doctors. Insurance was very simple 30 to 40 years ago. It evolved, or devolved if you prefer, into what it is today in response to the actions of providers and members.

Pre Existing limitations where inacted after people figured out they could wait and buy a policy when they were sick, get treated, then cancel it. When I started I couldn’t count the number of times a women called saying she just found out she’s x months pregnant and wants to buy a policy.

Pre Authorization didn’t start until hospitals were running needless test or keeping people admitted 2 to 3 times longer than needed.

When physicians started ordering needless or inappropriate test pre auth was expanded.

When medication was over prescribed, used off label, or not cost effective compared to existing medicines we implemented pre auth for Rx.

Doctors are far from fallible and need to be checked. Not to mention outright fraud.

You are incorrect about my position. I know there are doctors and patients who want coverage for medications and procefures that are not covered or not necessary. But insurance personnel are not all-knowing about medicine just because they see it 24/7/365. There are things they don’t know and need to be educated about. Some of them are willing to admit that but some aren’t.

Immune-compromised diseases are rare and something insjrance companies struggle with. I get it. Why do you think the Aetna case was about an immune-compromised patient on IVIG? But after 30 years, I am also convinced that some personnel look at this as (at best) something not worth understanding or (at worst) a good place to save money.

“Antibiotics are by far the drugs most frequently used in situations where they’ll provide no value for patients. The survey found that more than a quarter of doctors surveyed (27 percent) said that antibiotics are often administered to patients when the drugs will do no good.”

Pre Authorization didn’t start until hospitals were running needless test or keeping people admitted 2 to 3 times longer than needed.

Italics mine.

I doubt it was attending physicians who defined what was “needless or “longer than needed.” And before you go spinning into the “these decisions were made by Doctors” working with insurance boards, I will remind you that not all MDs have the same mandate, or similar agendas. I doubt that the creation of pre-authorization had its genesis in the concept of triage – extreme stewardship. I would argue that, pre-authorization had, instead, avarice for a father.

Simply put, the practice of pre-authorization was not founded on justice, but on bureaucratic fiat.

“The first care guidelines were written by Dr. Richard L. Doyle and published in a three-ring notebook. They presented advice, originally for health plans and insurers, to identify what the optimal care was in various healthcare situations.

Over our history, hospitals and other healthcare providers also started purchasing the care guidelines as they sought to align themselves with the guidelines U.S. health plans were following. Once providers saw the depth of MCG content, they recognized the inherent value and began using it inside their own institutions to guide care.”

I did not say that. I said that insurance company doctors should review the preauthorization requests made by patient’s doctors before the insurance companies can deny the request.

Do you see the difference? I’m doubt you do, or you wouldn’t have said what I quoted above.

If I were not fair, I would argue that it is you who advocates unchecked trust in insurance companies, even if they don’t have doctors reviewing preauthorization requests. But I doubt you believe that, or at least I hope you don’t. I do think you believe the insurance company should have the last word, no matter how they make their decisions. They do under our system and that probably has to be that way, but that is also why I think they should be transparent about how they make their decisions. Admitting that laymen or nurses are deciding what kind of care that patients get, not our doctors, would be a start.

I also think there should be automatic appeals of preauthorization denials, so we can be sure there is some medical review of decisions by actual doctors. I did not used to think that but seeing the Aetna admission and knowing what I know about insurance makes me think that would be a good thing. It might also prompt insurance companies to take preauthorization denials more seriously.

This discussion is a good illustration of why I rarely read the comments here anymore and rarely comment. I appreciate that some people engaged with me on a topic I care about and that they were willing to discuss the details with me. Further, I don’t care if people agree with me — I trust that when people sincerely try to understand a position they will fairly consider whether it is right or wrong. But the responses suggest to me that there was more of an effort to tell me I am wrong and not as much of an effort to understand my position. That rarely happens here anymore.

Further, I don’t care if people agree with me — I trust that when people sincerely try to understand a position they will fairly consider whether it is right or wrong. But the responses suggest to me that there was more of an effort to tell me I am wrong and not as much of an effort to understand my position. That rarely happens here anymore.

I know. It seems like the default position these days is “Well, that wasn’t my experience so it couldn’t possibly have been yours.” I confess that I am guilty of it too more than I should be. We’re living in the era where not only are we all sure that we are right, but we now have a platform to tell people just how right we are. We saw a lot of that with Obamacare too: one side saying, “Hey, I couldn’t get insurance for years and now I finally was able to purchase a policy, so Obamacare is awesome!” countered by the other side saying, “I had my insurance cancelled because it wasn’t in compliance and now my new policy is $300 a month more expensive.” It’s as if we cannot understand that both statements can be equally true.

… and for changing my position from asking that denials be reviewed to “every request.”

I wonder how many denials aren’t appealed, let alone taken to court? I don’t know … but I suspect that a very, very large percentage of denied claims and denied preauthorizations don’t end up in court.

259 You are correct, I would guess high 90s% aren’t appealed or taken to court. The overwhelming majority of denied pre-auths are things that obviously should not be done. I know you have no way of knowing this not working in the industry but we get a ton of absurd request.

Frankly, it wasn’t my goal but if this discussion is true, it has proved my point: Some insurance companies can’t afford to have doctors diligently and fairly review preauthorization requests, so they don’t. But that is their job. We don’t pay insurance so trained insurance staff can decide if our doctor know what they are doing. The insurance staff should only decide (1) if the policy covers the request and (2) if it is medically necessary. Laymen can decide the first but only doctors should deny the second.

I believe you get a lot of requests that are not medically necessary according to existing medical practices, and I agree that insurance should not have to pay for them. Perhaps that volume makes it hard to ever see any request as reasonable. If so, maybe that’s why denials need a second look.

Q:Do you have any idea the volume of pre auth request that came in daily? Many not from doctors.
A:Less than the number that are needed. This is the old inconvenience plea. There are more requests daily for insurance quotes, that get successfully answered. But volume is not the problem we are talking about; it is, what I call, the denial of service.

Q:Do you have a guess at how many hundreds of millions it would cost to have everyou request reviewed by a doctor?
A: yes, none. What’s your guess?

I understand your intent but it’s just not practical in the real world. For every doctor requesting pre auths another doctor would need employed to review them, your doubling the cost.

Bureaucracy increases the cost.

I would also guarantee that the less honest doctors would flood insurance with low cost pre auths knowing it would cost the insurance company more to review then to just pay it.

What? People gaming the system? Say it ain’t so.

It seems to me that you have surrendered to what you believe is practical . That’s fine -for you. But I am not persuaded to follow suit.

Pre Auth is based on the same medical best practices that doctors and hospitals use.

When providers are held to best practices and procedures who does it serve? The provider, the patient, the payor, and the responsible party. The entire system works best when everyone does what is best.

I said insurance companies have the last word in my comment 251, felipe, so Nate was probably responding to that. I was thinking of it in a contractual sense, in that once the company says it will not pay then there is no more negotiating. That only leaves appeals to the state insurance board or court, but that isn’t an option many patients use because their doctors typically won’t help patients after they exhaust their insurance denials.

It’s not an issue of what the insurance company can afford because the money doesn’t come from the insurance company. Premiums would increase to cover this added cost, so the question is can the public afford this added cost and what value do they receive in return? Do you want to spend 100 Million a year more so the same claims already approved are approved quicker?

” We don’t pay insurance so trained insurance staff can decide if our doctor know what they are doing.”

Actually we do, that is at the request of employers that sponsor plans and the government that pays for Medicare, Medicaid, and VA all of which have plan elements requiring the claims administer to decide if the doctor knows what they are doing.

Patients’ doctors will often take the main role in filing preauthorization requests, but typically patients have to file their own appeals or sue the insurance companies. It’s hard to do, especially when you are sick. IMO insurance companies know that delay can work in their favor.

266 Best care is defined by Medical Experts. You do realize nurses in doctors offices understand and apply these standards. Why is a nurse working in a doctors office more able than a nurse working at an insurance company?

Typically doctors offices file appeals, the ratio isn’t even close. We seldom get appeals from members, always from the providers. One of my pet peeves is the robo appeals. They don’t say what they are appealing just a form letter fired off saying we appeal.

I said insurance companies have the last word in my comment 251, felipe, so Nate was probably responding to that. I was thinking of it in a contractual sense, in that once the company says it will not pay then there is no more negotiating. DRJ (15874d) — 8/1/2018 @ 5:34 pm

“Providers request an average of 13.9 prior authorizations for prescriptions in a week, and 15.1 requests for medical services each week.”

For a provider to review every request would almost require a doctor working for insurance for every doctor requesting pre auths depending how they are submitted. Unfortunately technology has yet to make much of a dent in this process.

Or that the patient should agree to the filing? It would not be right for doctors to appeal without permission, but patients are so overwhelmed by medicine that I agree they do whatever doctors tell them to do.

Majority of the time patients request the provider to appeal, seldom would they appeal against the patients wishes. We have seen it though.

I do find that odd, unfortunately I have had many IVIG claims and some Hemophiliacs, because of the huge sums of money involved providers were usually very willing to put in the work. We have had providers sue on behalf of members, pay COBRA premiums for members, and put in Herculean effort when the potential payoff was great enough.

I don’t care about the volume, Nate. Would you accept it if a car insurer refused to pay for your car wreck damage because they had too many requests for coverage from customers? Don’t take the premium if you can’t apply your policy provisions in good faith, and one requirement is you determine if the procedure or medication is medically necessary. Nurses can’t always decide if you need neurosurgery. Why should they decide if you need high dose IVIG?

They can deal with it better with adult employees because they see the employees need IVIG to function, and they either like the employee, had them for years, or accepted the burden/cost when they hired them. It is harder with children who have no advocates but parents.

279 The things doctors get caught doing are scary. One of our big problems for years were back surgeries. Doctors would have the equipment rep in the operating room picking out what equipment to put in. We caught them putting in non approved or wrong screws and equipment all the time. We got out of some big claims catching them doing that. Member had no idea or was outright lied to about what was being put in them.

If we could magically do away with provider abuse and fraud 90% of complaints about insurance would go away. Unfortunately in the fight against fraud and abuse regular claims are also inconvenienced. The volume and $ amount of fraud and abuse doesn’t allow for it to be ignored to make things easier for the legit claims.

You are justifiably concerned with insurance fraud, Nate, and with controlling costs. Those are real concerns and volume-wise they are significant. But that doesn’t mean companies can structure the process to weed out abuse to the point that legitimate preauthorization requests are being denied en masse. And I think the distinction between claims and preauthorizations are important. It’s easier for companies to deny preauthorizations than claims because the cost of procedure/medicine has been incurred with claims. There is more pressure to pay them, but preauthorizations seem easier to deny.

My auto insurance company requires a claim and usually a police report, they don’t just pay everything I ask for the same day.

Ok, forget that analogy if it doesn’t work for you — although health insurance companies requires preauthorizations (in some cases), claims, and doctor’s orders, and they don’t pay the same day either.

Unfortunately in the fight against fraud and abuse regular claims are also inconvenienced. The volume and $ amount of fraud and abuse doesn’t allow for it to be ignored to make things easier for the legit claims.

Then you should build in safeguards to avoid those consequences that you know will occur.

“But that doesn’t mean companies can structure the process to weed out abuse to the point that legitimate preauthorization requests are being denied en masse.”

en masse is subjective, your definition I’m sure differs from mine.

From an oldish AMA survey, done 2010, 20% of first time prior authorization request are rejected, I don’t think it is that high.

Of that 20% denied only 80% are appealed. so the dispute appears to be over 16% of prior authorization request.

It doesn’t benefit the claims processor, especially when it’s not their money, to deny a pre auth that will ultimately be accepted. Their are providers, like genetic lab testing that submit high volumes of request for claims they know will never be accepted and will also file robo appeals.

80% approved first request to me means legit request are getting through the system just fine. Obviously your personal experience being the exception.

Actually there is a niche of plans that do pay same day. Members have a credit card and provider claims are processed in real time and provider takes payment before the member leaves the office. They have not been able to scale these plans up, they work great with small populations treated by good providers, once they try to expand they blow up.

We care about the problems but legally our hands are tied in many cases. Many states have laws saying we need to pay providers in 30 days and proving something is fishy doesn’t happen that fast.

Provider abuse also evolves at a rapid pace. The scams we bust or fight today are different than the scams 5 years ago, 10, 15, and 20. Back surgeries, sleep studies, genetic test, non network lab, were all issues at one time. Once we figure out and implement solutions for one abuse they find a new one.

Some IVIG requests are off-label so I understand there will be scrutiny, but there are times when the denials seem to unduly impact specific IVIG patients, including those who have diagnoses for which IVIG is medically necessary or appropriate. For example, MG patients last year. It’s not a high percentage of patients but it’s 100% if it is you.

293 this study out of Canada is similar to what I remember seeing but much more expensive here.

“There are several published guidelines that outline recommended uses of IVIG. These are largely based on case studies and expert opinion. Despite these guidelines, IVIG is often used in multiple settings where there is no supporting evidence.
In 2011, 227 patients received IVIG totalling 50,528g and 2.78 million dollars. In 2012, 216 patients received IVIG totalling 63,155g and 3.49 million dollars. According to published guidelines, 36% of the total usage in 2011 and 21% of the total usage in 2012 was not indicated (Figure 1). IVIG was prescribed the most by neurologists, hematologists, and rheumatologists (Figure 2). Despite the recent guidelines, the results show that there was no significant improvement in usage of IVIG between 2011 and 2012 (p-value 0.079, odds ratio 1.46).”

Nate, there are diseases for which IVIG is medically indicated and appropriate, and there are off-label uses. Insurance companies should not confuse the two. I hope you aren’t doing that, too.

Health insurance is complex, as is medicine. We can throw up our hands and say we are trying our best and it’s a shame if people get hurt but that is life. It is life. We can’t make a perfect world and we can only do our best. Getting back to the topic of the post, we are not so rich that we can solve every problem.

BUT that is why we have laws and procedures and contracts — so people can make informed decisions and protect themselves. Insurance companies need to try to live up to their contracts. If they regularly deny preauthorizations without competent medical reviews, that suggests a lack of good faith and that is a problem. Saying it is hard to do is not a good defense.

There needs to be also better access to medical records so they can be transferred to other physcians.

JVW (30a532) — 7/30/2018 @ 2:53 pm

Yeah, Bill Clinton and Newt Gingrich were touting this together twenty years ago, yet we have taken only very tentative steps of making this a reality. This is especially important for senior citizens who get over-proscribed medications because their various specialists don’t know what other drugs they are taking and the patient oftentimes doesn’t give a full accounting to each doctor.

The opposite has happened, with all these rules about the privacy of medical records.

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